The news headlines and the online chatter are full of chest-thumping claims from both political parties about saving democracy, scandalous finger-pointing at the other guys, battles over sound bites, and circus antics to grab the attention of the media. It is easy to get distracted by all the political drama and lose sight of important facts.
When it comes to health outcomes, the U.S. is leading the world in the amount of money spent on health care services but not getting the best health outcomes. We have shorter life expectancies than people in other industrialized countries. We have higher rates of obesity and chronic diseases compared to other wealthy nations. We also have more mental health diagnoses than other high-income countries, the highest rate of drug use disorders in North, Central, and South America, and the highest suicide rate in the world. While Americans do an excellent job training doctors in the management of medical problems, when it comes to preventing diseases and injuries, we are failing to implement strategies that will save lives and reduce costs.
For example, we know that the home environment, and in particular relationships with the people who take care of us, are critical to developing our ability to speak, communicate, and empathize with the experiences of others. When parents are unreliable, distracted by mental health problems and substance abuse, prone to anger and violence, then this increases the likelihood that children’s brains will be wired around fear and their bodies will be mired in stress such that they will have higher rates of obesity, chronic diseases, mental health and substance use problems, and suicide.
Given what we know, it would be logical to weigh the odds in favor of healthy homes so that children are more likely to grow up without physical and mental health problems. This would mean investing in families through evidence-based programs and policies. For example, nurse-home visiting programs improve mother and child outcomes and reduce costs for child protection, public education, health care, and criminal justice. In many countries, nurse-home visiting programs are universally provided to new parents, but in the U.S. these programs are offered to a limited number of families if at all.
Similarly, access to primary care reduces chronic diseases like hypertension and diabetes, and access to mental health care reduces the severity and impact of mental health and substance use problems. However, the U.S. does not offer universal health care and has significant shortages in both primary care and mental health workforces. My own specialty of preventive medicine and public health physicians could play a significant role in facilitating adoption of evidence-based clinical and community policy recommendations, and yet we are less than 1 percent of physicians in this country and we struggle to obtain funding for training since our focus is on prevention and not hospital-based care.
So why aren’t we investing in programs and policies that will lead to better health outcomes? My answer is politics which is tied up in a knot with American culture. In the continuum between making decisions that benefit individuals versus making decisions that benefit communities, American culture is skewed toward individualism. We believe in superhero stories that focus on individual strength, talent, or willpower, and overlook important facts about families, communities, and public policies that are needed for individual success. This shows up in many ways. In my own work, I have experienced the difficulties of shifting pediatric practice from a narrow focus on the individual child to one that addresses the family and community context, such as through partnerships with nurse-home visiting and community health worker programs. Calls to shift pediatric practice to a more family-centered model began over 100 years ago, and yet we are still struggling with barriers that include physician training, billing, and funding of community partnerships.
Another aspect of our culture is “us versus them” thinking. The American pursuit of “justice for all” has made important detours, like the genocide of native peoples, the enslavement of dark-skinned people, and discrimination against each new group of immigrants. This history matters because “us versus them” thinking continues to get in the way of improving outcomes. For example, rather than being willing to recognize that mental health and substance use problems affect all people, community initiatives often focus on the “the poor” who are often assumed to be “people of color,” i.e., “them.” However, the data is clear that no one group has a monopoly on mental health problems, and we would be more successful at getting to real solutions if we recognized our common need to learn how to manage stress and promote healthy relationships.
Arguably, belief in the American dream and that it should be accessible to all has at times allowed us to overcome aspects of our culture that separate and divide us. However, at this point in history, when the gap between rich and poor is widening while our political system is making it harder for the voices of the majority to be heard, at this point it is critical that we recognize that individualism and “us versus them” thinking are being exploited by politicians who are keeping us thumping our chests and fighting against each other while failing to deliver better outcomes.
The science is clear: investing in programs and policies that nurture human development is good medicine. The critical question is, when will we choose to let go of simplistic stories about superheroes and bad guys so that we can start working together to get the outcomes that we want?
Ariane Marie-Mitchell is a preventive medicine physician.
